Medical and Surgical Treatment of Chronic Anal Fissure - Chirurgia ...

J Gastrointest Surg
DOI 10.1007/s11605-007-0255-3
Medical and Surgical Treatment of Chronic Anal Fissure:
A Prospective Study
Pierpaolo Sileri & Alessandra Mele & Vito M. Stolfi &
Michele Grande & Giuseppe Sica & Paolo Gentileschi &
Sara Di Carlo & Achille L. Gaspari
Received: 16 May 2007 /Accepted: 19 July 2007
# 2007 The Society for Surgery of the Alimentary Tract
Abstract
The aim of this prospective study was to assess the efficacy of different medical treatments and surgery in the treatment of
chronic anal fissure (CAF). From 1/04 to 09/06, 156 patients with typical CAF completed the study. All patients were
treated with 0.2% nitroglycerin ointment (GTN) or anal dilators (DIL) for 8 weeks. If no improvement was observed after
8 weeks, patient was assigned to the other treatment or a combination of the two. Persisting symptoms after 12 weeks or
recurrence were indications for either botulinum toxin injection into the internal sphincter and fissurectomy or lateral
internal sphincterotomy (LIS). During the follow-up (19±8 months), healing rates, symptoms, incontinence scores, and
therapy adverse effects were prospectively recorded. Overall healing rates were 65.3 and 96.3% after GTN/DIL or BTX/
LIS. Healing rate after GTN or DIL were 39.8 and 46%, respectively. Thirty-six patients (23.1%) responded to further
medical therapy. Fifty-four patients (34.6%) underwent BTX or LIS. Healing rate after BTX was 81.8%. LIS group showed
a 100% healing rate with no morbidity and postoperative incontinence. In conclusion, although LIS is far more effective
than medical treatments, BTX injection/fissurectomy as first line treatment may significantly increase the healing rate while
avoiding any risk of incontinence.
Keywords Chronic anal fissure . Surgery. Botulinum
Introduction
The cause of anal fissure is still unknown, but hypertonia of
internal anal sphincter (IAS) associated with the passage of
hard stools is likely one of the main factors implied. As a
matter of fact, an elevated mean resting pressure of the IAS
(measured during anorectal manometry) is the most
Presented at the SSAT Annual Meeting, May 2007,Washington, DC,
USA.
P. Sileri : A. Mele : V. M. Stolfi : M. Grande : G. Sica :
P. Gentileschi : S. Di Carlo : A. L. Gaspari
Department of Surgery, University of Rome Tor Vergata,
Policlinico Tor Vergata,
Rome, Italy
P. Sileri (*)
University of Rome Tor Vergata, Policlinico Tor Vergata,
Chirurgia generale (6B) Viale Oxford 81,
00133 Rome, Italy
e-mail: piersileri@yahoo.com
consistent finding in patients with fissures. Lateral internal
sphincterotomy (LIS) has proved highly effective in curing
anal fissures in a number of randomized clinical trials 1–8 ,
with success rates higher than 90%. Although LIS is
currently considered the “gold standard” of treatment, it
encompasses an overall risk of incontinence, which can be
as high as 10%, as estimated in a systematic review of
randomized surgical trials. 9 Hence, the interest, in the last
two decades, in seeking new medical treatments is directed
at lowering the tone of the IAS. Glycerin trinitrate (GTN),
botulin toxin, and topical calcium channel blockers are all
known to be able to lower the IAS tone. The efficacy of
GTN has been evaluated in several randomized studies and
although the overall healing rate for GTN estimated in a
meta-analysis of the published randomized trials 10 is about
50%, it is established as a first line therapy in many centers
because of convenience, safety, and costs. The main
drawbacks of GTN treatment are recurrence, tachyphylaxis,
anal burning, hypotension, and the risk of headache that can
be so severe to cause many patients to abandon therapy.
The botulinum toxin is injected directly into the IAS and
produces a “chemical sphincterotomy.” It appears to be the

ideal agent to overcome the side effects of GTN, as it
produces the same reduction of the anal sphincter resting
pressure as GTN, there are no compliance issues, and
adverse effects are infrequently reported. A meta-analysis
of randomized clinical trials comparing medical treatments
to placebo or surgery 10 has shown that GNT, botulinum
toxin, and surgery have overall response rates of about 55,
65, and 85%, respectively, whereas the placebo healing rate
is about 35% across all the studies. Medical treatment
seems therefore a reasonable first line therapy for most
patients with chronic anal fissure (CAF). Second-line use of
botulinum toxin seems to heal only 50% of fissures
resistant to. 11 It is likely that the fibrotic nature of chronic
fissures resistant to GTN is not resolved by chemical
sphincterotomy alone. Fissurectomy alone is not currently
used in adults, but its combination with botulinum toxin
injection has been recently used with success to treat fissures
resistant to medical treatment. 12,13 with healing rates higher
than 90%. The aims of our study were the assessment of the
efficacy of different medical treatments, fissurectomy, and
botulinum toxin injection, and LIS in lowering the anal
sphincter tone and healing CAFs, and the development of a
treatment algorithm for patients with CAF.
Material and Methods
Between January 2004 and September 2006, 156 consecutive
patients with CAF were enrolled in the study.
Diagnosis was made according to history and physical
exam. CAF was defined by duration of symptoms longer
than 3months and the presence of a skin tag, a sentinel pile
or fibrosis at the margins of the fissure. Exclusion criteria
included atypical CAF associated with grade III/IV hemorrhoids,
previous anal surgery, incontinence, inflammatory
bowel disease, infection, or cancer. Patients with coexisting
medical conditions requiring calcium channel blockers and
oral, sublingual, or transdermal nitrates were also considered
ineligible for this study.
During the outpatient visit, a complete explanation of the
disease and the medical treatment options, benefits, and
side effects were given to the patient.
After this, patient was assigned to an 8-week course of
medical therapy with either 0.2% GTN or anal dilators
(DIL) according to his/her preference. Patients of GTN
group were instructed to apply the ointment twice a day to
the edge and just inside the anal canal (morning and
evening) after a warm sitz bath. The amount of crème to be
applied was shown during the outpatient visit. If patients
experienced side effects, he was instructed to use a finger
glove for application or to reduce the amount to be applied.
Patients of DIL group were instructed to use an anal
dilators set (Dilatan, Sapi Med, Alessandria, Italy) as
J Gastrointest Surg
follows. To ease the DIL introduction, after being heated
for 15min in water, patients lubricated the DIL with a preparation
gel (Dilatan crema, Sapi Med, Alessandria, Italy)
and introduced it fully into the anal canal and maintained
the position for 10min twice a day (morning and evening).
Patient was invited to repeat this procedure for 3 weeks
starting with small diameter dilators (20–23 mm), followed
by medium size dilators (23–27 mm) and ending with the
large (32 mm).
The primary end-point was fissure healing at last followup.
Secondary end-points were symptomatic improvement,
need for LIS, and side effects. Improvement was defined as
absence of pain or bleeding. Healing was defined as
complete epithelialization of the fissure base. Those
patients in which no improvement in symptoms was
observed after 8 weeks were crossed to the other treatment
(either GTN or DIL) or switched to a combination of the
two for additional 4 weeks. Botulinum toxin injection in the
IAS associated to fissurectomy (BTX-F) or LIS were
offered to patients who did not benefit from the 12-week
treatment course with GTN or DIL or a combination of
them, after full information about the risks and the benefits
of either procedure. Patients with non-healed or recurrent
CAF who refused surgery were offered a further medical
treatment. Anorectal manometry was performed before
either one of the procedures.
Either fissurectomy/Botox injection or LIS were performed
in a day-surgery setting under sedation and local anesthesia in
lithotomy position. Before surgery, all patients had a limited
bowel preparation with one Sorbiclis (Sofar S.p.a, Milan,
Italy). An Eisenhammer speculum was gently inserted,
avoiding excessive sphincter dilatation. Fissurectomy was
performed by minimal excision of the fibrotic edges of the
fissure and curettage of its base just back to fresh, normal,
non-fibrotic tissue. If present, the sentinel pile was excised
with cutting diathermy. Once fissurectomy was performed,
25U of botulinum toxin (Botox, Allergan, Milan, Italy) were
injected as follows. A volume of 1.6 ml of saline solution was
mixed into a 100-U vial of botulinum toxin, and 0.4 ml aliquot
(equal to 25U) was drawn up into a 1-ml syringe with a 27gauge
needle and injected equally into the IAS at 3 and
9o’clock.
LIS was performed using the open technique with partial
division of the IAS in the lateral position using coagulation
diathermy. In all cases, fissurectomy was performed as
previously described. 13
Patients in both groups were discharged on the same day
and stayed on a high-residue diet and stool softener for
7 days. A non-narcotic analgesic was also prescribed as
needed, and patients were advised to take regular warm sitz
baths. Patients were seen in outpatient clinic after 1 week
and therefore at 1-, 2-, 3-, and 12-month intervals.
Independently of these scheduled appointments, patients

J Gastrointest Surg
were seen on request. Information about fissure healing,
symptoms, complications, and adverse effects were prospectively
collected. Wexner incontinence score was used
to assess continence after the procedures.
Differences between treatment groups were evaluated by
chi-square test.
Results
Patients’ demographics, fissure characteristics, and treatment
failures are shown in Table 1.
Median follow-up was 19±8 months ranging from 3 to
33 months.
Overall fissure healing after medical treatment with either
GTN or DIL was observed in a total of 102 (65.4%) patients.
Figure 1a shows healing rates after 12 weeks treatment
with GTN or DIL alone as well as recurrences and overall
healing rates at the end of the study. Fig. 1b shows healing
rates, recurrences, and overall healing after the switch.
Healing after 12 weeks was observed in 52.7% of the
patients for the GTN only group and in 50.8% of the
patients for the DIL only group without significant differences.
Recurrence rate after 12 weeks treatment was 24.5%
for GTN only group and 9.4% for DIL only group
respectively (p=0.09).
In particular, healing with no recurrence was observed in
37 out of 93 patients (39.8%) treated with GTN alone and
in 29 out of 63 patients (46.0%) who underwent anal
dilation only. In most of the patients, healing time ranged
from 8 to 12 weeks after treatment course. No significant
difference was noted between the two groups in terms of
time to healing (p=0.1).
Seventy-five patients (48.1%) experienced non-healing
or sudden recurring disease within the first 8 weeks obser-
Table 1 Patients’ Demographics, Fissure Characteristics, and Treatment Failures Resume
vation period. Of those, 33 patients (previously treated with
GTN) were switched to DIL and 22 (previously treated with
DIL) to GTN for additional 4 weeks. The remaining 20
patients accepted a combined GTN/DIL treatment.
A total of 36 patients (23.1%) responded to this further
medical therapy, and overall healing rate raised significantly
from 42.3 to 65.4% (p=0.03). In particular, at the end of
this further 4 weeks treatment, GTN after DIL resulted
effective in 68.2% of the treated patients (15 out 22) and
DIL after GTN in 36.4% (12 out of 33) (p=0.02). Of the 20
patients treated with combined DIL/GTN, 14 responded
with healing (70%) (p=0.02 vs DIL and 0.90 vs GTN).
During the follow-up recurrence rates were 16.7% for DIL
after GTN, 7.1% for combined GTN/DIL, and 14.3% for
GTN after DIL, with no significant differences among
groups. Fig. 1b shows definitive healing after this further
medical treatment. Definitive healing was observed in 10 out
of 33 patients treated with DIL after GTN (30.3%), in 13 out
of 22 patients treated with GTN after DIL (59.1%), and in 13
out of 20 patients treated with combined GTN/DIL (65%).
Combined GTN/DIL and GTN after DIL treatments were
similar in terms of definitive healing and significantly better
than DIL after GTN treatment (p=0.003).
At the end of the study, overall medical treatment
success was 60.2% (56 out of 93 patients) and 73% (46
out of 63 patients) respectively for patients initially treated
with GTN or DIL. No significant differences were observed
between the groups.
Overall incidence of GTN side effects was 12.8% (15
patients), mostly mild headache (9 patients) and pruritus
ani (6 patients ). Five patients (4.2%) discontinued therapy
and were switched to DIL.
A total of 107 patients were treated with DIL (63 patients
as initial treatment and 44 patients after GTN treatment) and
12.1% interrupted the DIL course (13 out 107) because of
GTN DIL GTN/DIL BOTOX/fissurectomy LIS
Number 93 63 20 22 32
Mean age (years) 37 41 39 34 43
Sex (M/F) 42/51 29/34 8/12 10/12 11/21
Fissure position
Post 74 49 13 19 28
Ant 14 11 5 2 3
Both 4 3 2 1 1
Other 1 0 0 0 0
Sentinel pile N/% 61/65.6% 39/61.9% 14/70% 15/68.2% 27/84.4%
Single treatment (12 weeks) success N/(%) 49/93 (52.7%) 32/63 (50.8%) NA NA NA
Recurrence 12/49 (24.5%) 3/32 (9.4%) NA NA NA
After cross-over healing N/% 12/33 (36.4%) 15/22 (68.2%) 14/20 (70%) NA NA
Recurrence 2/14 (14.3%) 2/15 (13.3%) 1/14 (7.1%) NA NA
Overall success N/% 47/93 (50.5%) 42/63 (66.7%) 13/20 (65%) 18/22 (81.8%) 32/32 (100%)

Figure 1 Healing after
12 weeks, recurrence rates, and
overall definitive healing after
single medical treatment (a) and
after the switch (b). Data is
expressed as percentage of
treated patients.
severe discomfort. After non-healing or recurrence, surgery
was offered to 53 patients (34%). One patient refused either
botulinum treatment or surgery, and further medical treatment
was offered with minimal beneficial effect. Of the
remaining 52 patients, 22 underwent fissurectomy/Botox
injection and 30 to LIS. Healing was reported in 18 out of 22
(81.8%) patients after fissurectomy/Botox injection. This
percentage was significantly higher compared to GTN alone
course (p=0.008), to DIL alone treatment (p=0.02) or to
overall combined/cross-over groups (p=0.01). One patient
(4.5%) experienced transitory flatus incontinence. Nonhealing
was observed in one patient (4.5%) and recurrence
in 3 (13.6%). Two out four subsequently required LIS
because of recurrent disease (one patient) or failure of therapy
in promoting fissure healing (one patient) and had complete
healing. The remaining two patient refused further surgical
treatment and remained on periodical medical treatment.
All 32 patients treated with LIS showed complete
healing with no morbidity or postoperative incontinence.
Comparing the different treatment groups, there were no
significant differences in terms of healing rates between
males and females, presence or absence of sentinel pile, or
previous GTN or/and DIL treatment.
Discussion
The most recent theories on etiopathogenesis of anal
fissures have focused on increased tonicity of the IAS,
which contains smooth muscle fibers whose contraction is
controlled by neural influences and myogenic mechanisms.
14,15 IAS contraction is mediated by increased cytosol
calcium levels. Nitric oxide serves as the main neurotransmitter
in the IAS causing relaxation of the muscle fibers. 15
Numerous clinical evidences pointed out the role of an
elevated resting pressure of the IAS in patients with anal
fissures. 16,17 Factors causing IAS hypertonia are not well
understood, but a significant role in perpetrating the muscle
spasm is played by the trauma caused by the passage of hard
J Gastrointest Surg
stools on the mucosa. 18 Spasm of the sphincter not only
promotes constipation (thus setting up a vicious cycle) but
also leads to compression of the terminal arterioles supplying
the mucosa of the anal canal. 19 Impaired blood flow in
this already poorly perfused area prevents fissure healing.
Since the introduction of the posterior internal sphincterotomy
by Eisenhammer 20 in 1951, CAF has been managed
with surgery once conservative measures failed. The more
safe lateral sphincterotomy, popularized by Notaras 21 in
1969, has until recently been the mainstay of treatment to
reduce the pathologically raised pressure profile within the
anal canal. Despite that surgery is highly efficacious and
succeeds in curing CAF in more than 90% of patients (often
exceeds 95% with high patient satisfaction), postoperative
impairment of continence is not uncommon. 10,15 The
incidence is not well documented and varies between 0
and 35% for flatus incontinence, 0 and 21% for liquid
incontinence, and 0 and 5% for solid stool incontinence. 22–25
As indicated by Nelson in a recent systematic review of
randomized surgical trials, the overall risk of incontinence
is about 10%, 9,10,26 mostly to flatus without any specification
of the duration of this problem (transitory or
permanent). However, it is a common belief that the risk
of permanent incontinence is about 1%. Nonetheless, this
does not take into account normal weakening of the
sphincter with age and the possibility of future anorectal
surgery, radiation, or obstetrical trauma. Therefore, the risk
of incontinence after LIS should be considered lifelong, to
an often young, otherwise healthy person.
To minimize this risk, several authors have tried a more
limited division of internal sphincter, a tailored or controlled
sphincterotomy, but additional remarkable data is needed. 27,28
In the late 1990s when alternatives to surgery were
sought because of risk of incontinence, costs, and time for
recovery, newer medications directed at relaxing increased
sphincter tone or enhancing mucosal blood flow were
investigated. These included nitroglycerin ointment, calcium
channel blockers (either given as tablets or topically),
and recently, injection of botulinum toxin.

J Gastrointest Surg
GTN causes sphincter relaxation by acting as a nitric
oxide donor and improves anodermal perfusion. 29 Topical
calcium channel blockers like diltiazem and nifedipine
induce IAS by decreasing cytosolic calcium concentration.
Despite that early trials (including both acute and
chronic fissure) of conservative medical treatments showed
overall healing rates and pain relief close to surgery, usually
results with medical treatments are only marginally better
than placebo or conservative therapies alone (fiber, Sitz
baths, and topical lidocaine) with healing rates between 36
to 68% and relapses rates as high as 35%. 30,31 According to
Nelson’s meta-analysis, a marginal advantage in using GTN
(55%) over placebo (35%) exists, but no statistical
difference was found comparing GTN to either botulinum
toxin or calcium channel blockers.
We used GTN ointment in addition to conservative
approaches (fiber and Sitz bath) as first line treatment
because of its safety, convenience, and cost. The dosage and
number of applications previously reported ranges from 0.2
to 0.5% and from twice to four times per day. 32,33 Dose
escalation or use of a transdermal patch has not been shown
to improve the healing rate. 34,35 The principal side effect is
headache, seen in up to 50% of patients and less commonly
anal pruritus. 31,36–38 Hence, compliance issues are observed
in up to 72% of patients, and about 20% of patients will
discontinue therapy. 26,35,39
As 0.2% dosage seems to be as effective as 0.5% dosage,
with less side effects, we decided to offer a 0.2% twice a
day treatment. Our healing rate after GTN alone treatment
was close to 40% increasing to only 50.5% when DIL
course was added. We also observed a 24.5% recurrence
rate, significantly higher compared to DIL use only or
combined GTN/DIL. In our series, the incidence of side
effects associated with GTN application was lower (12.8%)
than the common incidence of at least 20–30% reported in
literature. Only 4% of the patients discontinued the therapy
and were switched to DIL. Surprisingly, in our series, the
most common reason to discontinue GTN therapy was anal
pruritus, observed in 5% of patients.
We believe that the low incidence of side effects and
good compliance to treatment program showed by our
groups of patients is the result of reduced number of applications
(twice a day) and the accuracy of instructions given
to the patient at the time of the outpatient visit.
The rationale for the use of anal dilators (DIL) is the
finding that they induce muscle relaxation with consequent
reduction in sphincter hypertonia. Moreover, blood
flow is improved in the IAS, thus favoring fissure healing.
When the DIL is heated, the relaxing effect is enhanced. 38
Short-term healing rates are reported as high as 95% when
used in combination with GTN, with about 10% reduction
after 2 years follow-up. However, little evidence on the
efficacy of anal dilators is present in the literature.
Recently, Schiano et al. 38 reported healing rates of 75%
with DIL only and 93.7% with combined GTN/DIL treatment.
In our experience, the DIL-only treatment was
associated with a 46% healing rate, slightly superior to
GTN use only. However, recurrence rate was significantly
lower.
When DIL group was switched to GTN because of nonhealing,
the success rate increased to 66.7% significantly
higher than the success rate of 50.5% observed when GTN
course was followed by DIL. We explain this difference
with a shorter healing time observed with GTN compared
to DIL course that needs few weeks of applications of
different size dilators. A 4-week DIL course may not be
sufficient to significantly increase the healing rate after
GTN, thus reducing the likelihood of surgery. An indirect
evidence of this is observed in patients simultaneously
treated with DIL and GTN who showed a definitive healing
rate of 65% with a very low recurrence rate (7%). This
result might be indicative of a possible synergic effect of
the two. Schiano et al. reported a 93.5% healing rate;
however, our follow-up was longer. In our experience, DIL
use is safe, healing rates are comparable to GTN treatment,
but compliance is lower. In our experience, 12.1% of the
patients interrupted the DIL course because of severe
discomfort preferring “less invasive” approaches. The
reluctance in using DIL after GTN failure and the reduced
compliance may also explain the low healing rate observed
in this group.
Injection of botulinum toxin into the internal sphincter
produces a temporary chemical sphincterotomy that allows
fissure healing.
The botulinum toxin is believed to act at the postganglionic
level reducing noradrenaline output from sympathetic
neural terminals in the internal sphincter and possibly
also by reducing myogenic tone in this tissue. 28 A single
botulinum injection is well tolerated, with minor side
effects, thus eliminating non-compliance issues. It reduces
maximum resting pressure by a similar proportion to that of
GTN (25–30%) 39 over a 2- to 3-month period of time. 22
The most common side effect is transient incontinence to
flatus (up to 10%) or feces (up to 5%). 40
Recurrence are common but may be easily treated with a
good rate of healing even if up to 20% of patients will need
LIS. 26,41,42
There is no consensus on dose, site, or number of
injections. 43 However, a dosage between 20 and 25U, and
anterior injection seems more effective and causes no
additional side effects. 14,15,37 A transient decrease in mean
squeeze pressure can also be observed when higher doses
are used. 40,44 Conversely, higher doses are not proven to be
more effective. 45
Despite that early trials have shown healing rates as
high as 90% for acute and chronic fissures, the enthusiasm

was tempered by the disappointing results on CAF.
Lindsey et al., 11 in a prospective study of 40 patients with
GTN-resistant fissures treated with 20U of botulinum,
reported a healing rate of only 43%. Similarly, Minguez
et al. 46 did not show healing rates as high as surgery after
botulinum injection with a 42 months follow-up, while
Arroyo et al. 47 and Mentes et al. 48 observed 1-year recurrence
rates after botulinum injection approaching,
respectively, 50 and 40%. Higher healing rates are observed
if botulinum is given early, before the chronic fibrosis of
the fissure is established. 39 As botulinum injection treats
only the internal sphincter spasm, Lindsey et al. 22 have
proposed to add fissurectomy to chemical sphincterotomy,
reporting a healing rate of 93% for medically resistant CAF.
In a more recent study, Scholz et al. 12 reports excellent
results with implementation of the fissurectomy–Botox
injection technique, which proved to be effective in treating
fissure recurrences, too.
Fissurectomy enhances healing by removing the fibrotic
fissure edges, unhealthy granulation tissue at the base, and
the sentinel pile when present. 22
We adopted this novel sphincter-sparing procedure as
second line treatment after failure of GTN and/or DIL
course. We observed a long-term healing rate of 81.8%,
significantly higher than the one reported after all other
approaches. Along with Lindsey et al, we believe that
fissure healing is significantly higher with fissurectomy–
botulinum toxin injection compared to medical treatment
alone because with this treatment, we are able to address
both elements of chronic fissure, chronic fibrosis, and
internal sphincter spasm. We observed a single case of
transitory incontinence, and our data confirm the safety of
this treatment. The main drawback of this approach is the
need of an operating theater and the costs. Although four
patients of this group experienced fissure recurrence or nonhealing,
with two requiring subsequent LIS, fissurectomy
and botulinum injection reduces significantly the need of
LIS. The paucity of minor side effects associated to the
good healing rates indicate that botulinum injection/
fissurectomy may be used as first line approach for selected
CAF even without previous medical treatment. Along with
Lindsey et al., our study confirms that medical treatment
alone for chronic, well-established fissures might be
inappropriate, merely delaying definitive fissure healing. 13
Features of chronic fissure such as a fibrotic tissue, skin tag,
or sentinel pile predict poor healing with medical therapy,
and disappointing results of medical therapies for CAF,
often similar, or just superior to placebo in different clinical
trials, strengthen this observation. As a consequence of our
experience and literature evidence, we believe that BTX/
fissurectomy should be offered as first line treatment for
patients with typical CAF even without previous medical/
conservative treatments. Patients at high risk for anal
incontinence, young female patients, and patients with
previous anal surgery can also be treated with BTX/
fissurectomy. Botulinum toxin injection associated to a gentle
fissurectomy seems to be very safe, reducing greatly the
likelihood of surgery and abolishing the risk of incontinence.
The main drawback of BTX/fissurectomy is the need of
surgery and the costs. However, we believe that the prompt
and excellent healing rates (close to LIS) and the absence of
severe side effects or complications might justify the costs.
Failure of BTX/fissurectomy or recurrence indicate the
need of LIS.
Our study confirms that LIS represents the most effective
approach to CAF. Although transitory postoperative incontinence
can been observed in up to one third of patients, in
our experience, we did not incur in any. Nonetheless, we did
not observe any permanent incontinence. Although the
proximal extent of the LIS continue to be a topic of debate,
in our experience, by ‘tailoring’ the amount of sphincter to
be divided to the length of the fissure, the risk of
incontinence is minimized and the fissure healing achieved.
To enhance and accelerate healing, we also believe that an
accurate fissurectomy should always be added to LIS.
Conclusions
Although surgery (LIS) may be appropriately offered
without a trial of pharmacological treatment after failure
of conservative therapy as indicated by the “Practice
parameters for the management of anal fissure”, being
incontinence as a lifelong risk, a step-wise approach would
be appropriate and a trial of topical GTN and/or DIL should
be offered. However, as refractory CAF with fibrotic tissue
may heal with fissurectomy and botulinum injection only,
abolishing the risk of incontinence, this approach should
also be offered especially if patients are reluctant to
undergo LIS or at high risk for incontinence. Moreover,
according to our experience, this approach as first line
medical treatment seems to be rational, safe, and effective,
but further data is needed.
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J Gastrointest Surg
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